Page 1

IMHO
Project
Report
Form
 
 As
our
local
partners,
it
is
necessary
for
you
to
report
back
to
IMHO
on
the
progress
you
are
making
with
 your
efforts
and
to
provide
us
with
accurate
financial
records
of
how
the
funds
given
to
you
by
IMHO
 have
been
spent.
We
request
that
you
fill
in
this
form
to
the
best
of
your
ability
on
a
QUARTERLY
basis,
 the
frequency
of
which
depends
on
the
overall
timeframe
of
your
project.
It
is
your
responsibility
to
 report
back
to
us
using
the
format
outlined
below.
Future
installments
of
funds
will
not
be
disbursed
 without
receipt
of
this
Project
Report
Form.
Please
ensure
you
include
the
following:

 
 1. Please
fill
out
the
attached
IMHO
Project
Report
Form
as
completely
and
accurately
as
possible.
 
 2. Upon
completion
of
the
project,
send
this
form
back
with
your
expense
summary,
outlining
how
 the
funds
were
spent
on
the
project.
Please
use
the
attached
IMHO
Project
Expense
Summary
 Form
and
fill
it
in
as
completely
and
accurately
as
possible,
unless
you
prefer
to
use
your
own
 method
for
reporting
your
expenses.
 
 a.
Include
copies
of
ALL
receipts
related
to
project
expenses.
If
no
receipt
is
available,
 please
make
a
note
of
it
in
the
form.
 
 3. If
this
is
the
first
quarterly
IMHO
Project
Report
Form
you
are
filing
and
you
have
not
already
 done
so,
please
send
it
back
with
a
written
acknowledgement
(on
your
organization
letterhead,
 if
possible)
of
receipt
of
funds
from
IMHO.
Make
sure
to
date
the
letter,
and
specify
the
amount
 received
from
the
International
Medical
Health
Organization
(IMHO)
as
well
as
for
what
 purposes
you
were
given
the
funds.
This
acknowledgement
is
critical
for
our
records,
so
please
 do
not
delay.
 
 Please
note,
any
significant
changes
to
the
project/program
as
outlined
in
your
proposal,
including
 project
budget,
must
be
pre‐approved
by
the
IMHO
Board
of
Directors.
Thank
you
for
your
cooperation
 and
for
the
invaluable
work
you
do.
Please
contact
us
if
you
have
any
questions
or
need
any
clarification,
 or
if
you
would
like
to
discuss
any
particulars
about
your
project.
 
 Sincerely,
 
 IMHO
Board
of
Directors
 
 
 
 
 
 
 
 
 
 Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


Project
Report
Form
 
 Date:__________________________________________
 
 Title
of
Project/Program:________________________________________________________________
 
 Name
and
Address
of
Organization:_______________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 Name(s)
of
Key
Contact
Person(s)
for
Project:_______________________________________________
 
 Phone
Number(s):_______________________________________________________________
 
 Email(s):_______________________________________________________________________
 
 Fax:___________________________________________________________________________
 
 Please
briefly
describe
the
progress
you
have
made
with
this
effort
in
the
last
quarter:_____________
 
 _____________________________________________________________________________________
 
 ____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 ____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 Please
describe
how
the
target
population(s)
has
benefited
from
this
effort
this
quarter:____________
 
 _____________________________________________________________________________________
 Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


_____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 Please
describe
how
the
funds
IMHO
has
given
you
for
this
project
have
been
used:_______________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 What
challenges/difficulties
have
you
encountered:__________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 Are
your
project
goals
still
the
same?
(if
not,
please
elaborate):_________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 Other
Information/Comments:___________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 *Please
include
any
photos
or
additional
information
as
you
see
fit.
 Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


Statement
of
Verification:
 
 I
hereby
certify,
to
the
best
of
my
ability,
that
all
of
the
information
contained
in
this
form
is
true
and
 accurate.
 
 ______________________________________________
 ___________________
 Sign
Name
 
 
 
 
 
 
 Date
 
 _________________________________________
 ____________________________
 Print
Name
 
 
 
 
 
 Title/Position
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


Additional
Space
(use
pages
as
needed)
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 
 _____________________________________________________________________________________
 Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


Expense
Summary
Form
 
 
 Date



 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Vendor
Name


Description


Amount


Copy
of
Receipt
 Included?
(Y/N)
 


Notes/Comments


Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org


Date
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 


Vendor
Name


Description


Amount


Copy
of
Receipt
 Included?
(Y/N)


Notes/Comments



 


Federal Tax ID Number: 59-3779465 P.O. Box 61265, Staten Island, NY 10306, USA. www.TheIMHO.org Email: contact@theimho.org

IMHO project report form  

Report Form for IMHO-funded activities

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